2.0 Analysis 2.1 Charter Company's Safety Information for Guests The content and quality of the safety information contained in the booklets given to the guests and of the reminders posted on each boat show that the charter company takes seriously its obligation to inform guests on matters relating to their safety while on board the mother ship or when out fishing. 2.2 Charter Company's Safety Procedures - Radio Although the importance of maintaining radio contact is stressed in the safety information given to guests, there was no scheduled radio reporting regime in place. As a result, it was not discovered until long after the fact that the CE4 may have been in difficulty. Because there does not appear to have been any great stress on the utility of a regular reporting regime and the correct use of the VHF radio, the guests did not, in the main, comply with the instructions of several members of the crew to report regularly. However, the instructions on radio use, posted on the boat, were clear and unequivocal. 2.3 Charter Company's Safety Procedures - The Buddy System According to the Fish Master's Role section of the company's in-flight information booklet, the fish master's paramount duty is to ensure the safety of all guests. His first priority, after safety, is to ensure that guests maximize their catch. While the safety information emphasizes the advantages of the buddy system and the dangers of fishing alone, a system to ensure compliance was not enforced by the corporate representative, the master or the fish masters. Because the buddy system was not enforced for those guests fishing away from the main areas, the CE4 was not seen after noon. No one was aware of the capsizing, which went unwitnessed and unnoticed until a physical check of boats was made at about 2015. 2.4 Fish Master's Duties The secondary duty of the fish master, to assist guests to maximize their catch, appears to have conflicted with the paramount duty of ensuring the guests' safety. Neither the master nor the corporate representative insisted that the fish masters patrol and sight all the guests or boats on a regular basis during either the morning or afternoon watches. 2.5 Charter Company's Safety Procedures - Watch Hand-overs When the weather was good, the practice on board was that the morning fish master did not give a full and detailed hand-over report to the afternoon fish master. Consequently, the afternoon fish master did not carry out a complete visual and radio check of the guests and their whereabouts, but set out to go fishing with one of the guests. Because the good weather relaxed the vigilance of both fish masters, the safety overview of the guests' whereabouts was correspondingly reduced. Although he spoke to some of the guests during the afternoon, the afternoon fish master did not see another boat until approximately 1600. The effect of not carrying out patrols or comprehensive radio checks was that no one was aware that the CE4 was missing until after the time it should have returned to the mothership. 2.6 Stability of the CHARLOTTE EXPLORER4 From the outset, the charter company had attempted to ensure that the small fishing boats were stable for their purpose and intended use. The stability of the boat was such that, in moderate weather, three people could stand on one side to haul a 120-kilogram fish aboard, without immersing the gunwale. However, the CE4 may have been overwhelmed by a wave or swell, or a combination of both, which exceeded the boat's design capability. Such a combination was possible given the sea conditions known and observed to have existed in the vicinity of the north-west corner of Hippa Island on the day of the accident. While the breach of the integrity of the starboard aft buoyancy tank would have reduced the buoyancy aft if it became flooded, the tank is not large and the loss of buoyancy would not have been a crucial or a significant factor contributing to the accident. If one occupant was attempting to rescue the other person over the transom, the tank may have had some effect on the operation. 2.7 Condition of the Recovered Boat The settings of the controls, as found, indicated that the outboard motor had been taken out of gear. However, because the console to which the controls were fixed had been ripped off the boat, the control lever may not have been in the neutral position when the boat was overwhelmed. Although it is less likely, a similar situation may exist with regard to the position of the on/off switch. As a result, no positive inference as to the position of the controls at the time of the accident may be drawn. 2.8 Indications that the CHARLOTTE EXPLORER4 Capsized Because there was neither a witness to the tragedy nor a survivor, the precise sequence of events is unknown. There is, however, evidence which points to the CE4 having capsized offshore of the kelp bed where it was last seen fishing. The indications that the CE4 capsized were that the damage to the consoles and seats and to the top of the outboard motor was consistent with that which would be caused by a capsized boat grounding on the beach (see AppendixE, photographs1 and 8); and that the bottom of the boat (see AppendixE, photographs3 and 4) showed no signs of grounding damage. Because there was no sign of kelp on the motor or in the propeller when the boat was recovered, it is likely that the boat capsized offshore of the kelp where it had been seen and where large swells were measured that day. Further, some of the loose equipment was seen in the kelp bed offshore from the beach where the boat was discovered. One piece of equipment in particular was the halibut harpoon and its plastic float. Its normal location and stowage are such that the boat would have to have been capsized for the harpoon to fall out. All indications are that the CE4 capsized offshore of the kelp bed near the beach where it was later found. 2.9 Cause of the Capsizing The sequence of events leading to the capsizing is unknown. While the male guest had satisfied the crew of the CHARLOTTE EXPLORER that he could handle the CE4 while in Nesto Inlet, he may not have had sufficient boat handling experience to appreciate the danger of the effect of the rocks and foul ground on the heavy swells north-west of Hippa Island. Because the female guest did not have sea fishing or boat handling experience, it is likely that she relied on the male guest's greater knowledge of the area. The motor may have stalled or it may have been switched off while the boat's occupants were preoccupied fishing or landing a fish. There is also a possibility that the motor cowling had been removed to inspect or repair the motor. Alternatively, one of the guests may have accidentally fallen overboard while fishing in the heavy swell. The motor may have been stopped by the other to attempt a recovery over the lowest part of the transom, adjacent to the motor. During any such rescue attempt, it would not have been possible to manoeuvre the boat. With the motor stopped, the boat's occupants would not have had the ability to manoeuvre clear of areas of danger in the foul ground off Hippa Island. It is most likely that the boat drifted on the tide into this area of confused and breaking swells, and capsized. The lack of bottom damage to the boat indicates that it did not capsize as a result of having grounded on the rocks in the area. 2.10 Search and Rescue The guests in the CE4 were not missed until after the time they should have been back at the mother ship, but once it was determined that the boat was missing, the master and the corporate representative quickly organized an exhaustive search of the immediate area. However, because the CGRS was not called until after the initial search was unsuccessful, the main RCC-directed search was not launched until the next morning. 3.0 Conclusions 3.1 Findings The guests on board the CHARLOTTE EXPLORER4 (CE4) were fishing in the vicinity of the kelp bed on the north-west corner of Hippa Island. The area in which the guests were fishing is foul ground around which the ocean swell increases in height, breaks and causes heavy confused seas. The sea swell increased during the day and peaked at about 1330, when a maximum wave height of seven metres was recorded at the weather buoy. Prior to being allowed to fish away from the group, guests were not adequately screened to determine their level of experience of the marine environment and boat handling. The guests may not have had the boat handling experience to deal with the conditions encountered when increasing swells and tidal forces pushed their boat toward the rocks and kelp bed. The motor was most likely stopped by one of the guests prior to the boat capsizing. Guests fishing away from the main areas did not use the buddy system and its use was not enforced by the corporate representative, the master or the fish masters. Although the importance of maintaining radio contact is stressed in the safety information given to guests, there was no scheduled radio reporting regime in place. Neither the master nor the corporate representative insisted that the fish masters patrol and sight all the guests or boats on a regular basis. The secondary duty of the fish masters, to assist guests to maximize their catch, appears to have conflicted with the paramount duty of ensuring the guests' safety. The charter company's procedures, as set out in the safety information given to guests, were neither followed by the victims nor enforced by the company at the operational level. 3.2 Causes The chartered CE4, while fishing alone with the outboard motor most likely stopped, capsized after drifting into an area of kelp and rocks where a combination of tide and sea swell was locally creating large waves of up to, or larger than, seven metres with breaking crests. The charter company's procedures with regard to fishing alone, maintaining regular radio contact and patrols to ensure the safety of its guests were not enforced. There was delay in determining that the small boat was overdue and in starting a search. As there was no witness, the exact location, time and cause of the capsizing could not be determined. 4.0 Safety Action 4.1 Safety Concern In its investigations, the Board continues to find that there are safety shortcomings with small passenger and charter vessel operations. The Board has recommended stronger regulatory oversight to offset shortcomings in the management of the small companies engaged in these largely tourist operations. In addition, the Board has observed that efforts may be warranted to increase public awareness of necessary safety provisions for such operations. To date, the Board's work has not revealed to what degree the risks observed in the industry as a whole are present within the wilderness fishing or fishing lodge segment of the charter industry. Certainly, the investigation into the capsizing of the CHARLOTTE EXPLORER4 indicates that practices such as a buddy system and scheduled radio check-ins would eliminate some of the risks. In this unique industry, the operator and the client must rely on each other and systems will be effective only where the operator and client work together to ensure that safe practices are understood and followed. The Board recognizes the diverse nature of the industry, but given the safety issues identified in tourist charter operations in Canada and the specific concerns raised by this investigation, the Board is of the opinion that practices within the wilderness fishing industry as a whole bear further review. Transport Canada, the Canadian Coast Guard and the industry are those best placed to co-operate in an examination of current practices and to consider the best means for mitigating the risks resulting from identified safety deficiencies. Possible options could include, but not be limited to, regulatory requirements, an industry code of practice monitored by Transport Canada, or voluntary standards set and monitored by the industry itself.